by Kelly Kennedy, USA TODAY

by Kelly Kennedy, USA TODAY

WASHINGTON - The decision of some states not to expand Medicaid means that the nation's poorest - those the Affordable Care Act would have helped the most - may not receive any help at all.

That's because the 2010 law was written to provide Medicaid coverage for those making less than 100% of the federal poverty level, $23,550 for a family of four, in all 50 states. Because those Americans were to get Medicaid coverage, they were not made eligible for the federal tax subsidies that would help them pay for health insurance they will be required to buy.

However, when the Supreme Court ruled last year that the requirement for most uninsured Americans to buy insurance was constitutional, it also ruled that the states did not have to expand Medicaid to continue receiving federal funds for their existing programs.

That leaves out almost 7 million adults ages 19 to 64 who would have qualified for Medicaid in the 25 states that have not voted to expand it, according to an Urban Institute report. Medicaid is the federal-state health care program for low-income Americans. It covers 60 million children younger than 18, pregnant women, blind or disabled people. Other adults don't typically qualify.

Those 7 million people will neither get Medicaid nor federal help to buy health insurance.

"Because of the Supreme Court decision, this is a problem that only the states can fix, so they're going to have to think about this," former president Bill Clinton said in a speech Wednesday.

The expansion included in the law allows states to provide Medicaid coverage for adults who make less than 138% of the poverty level for three years with the federal government paying all of the extra costs. After three years, the federal share will remain 90% and the states will pay 10% of the expansion costs.

The Department of Health and Human Services issued a final rule in August exempting people from penalties for not having insurance if they would have qualified for Medicaid coverage had their state chosen to expand the program.

Many states with Republican governors and legislatures have rejected the expansion, calling it too expensive. Last month, Texas Gov. Rick Perry said, "In Texas, we've been fighting Obamacare from the beginning, refusing to expand a broken Medicaid system and declining to set up a state health insurance exchange. We took these steps to minimize the damage Obamacare will cause to our economy and state budget, although we're all too aware Obamacare will still cause our state immense budgetary challenges in the years ahead, just like it will to families and small businesses across our country."

In Texas, 1,326,000 adults ages 19 to 64 make less than 100% of the poverty line and would qualify for Medicaid. "Texas will not be held hostage by the Obama administration's attempt to force us into this fool's errand of adding more than a million Texans to a broken system," Perry said.

But not all governors feel the same. This week, Michigan's Republican-controlled legislature passed a law expanding Medicaid, which Republican Gov. Rick Snyder said he will sign.

"Hundreds of thousands of Michiganders will have the opportunity for health care coverage," Snyder said after the vote. "It's a situation that will also save all Michiganders money, in terms of addressing an unmanaged, uncontrolled system."

But that leaves 25 states that do not plan to expand the program.

"You get the worst of all worlds," Clinton said. "I'm sorry, but you're working 40 hours a week, but you're too poor to get help. This is a serious problem."

The Medicaid gap could cause a series of related issues, experts say. Consumers may be discouraged from applying for benefits for which they are eligible or parents with children eligible for benefits may not learn their kids can get help even if the parents can't.

In some states, there's no mention of the Affordable Care Act on governors' websites, leading people to assume there are no health exchanges. Exchanges are websites where the uninsured can buy private insurance through either state- or federal-run programs. Those who make between 100% and 400% of the federal poverty level may be eligible for subsidies that can be applied immediately to their insurance. Those sites may be found at healthcare.gov.

"I would say there's a lot of confusion," said David Sandor, vice president of public affairs for Health Care Service Corp., which operates Blue Cross Blue Shield in Texas, Oklahoma, Illinois and New Mexico. "Medicaid's a fluid situation. It can vary even within the same household."

For example, a woman may have children eligible for Medicaid, but if no one asks her if she has children, she may not realize they can get Medicaid coverage, said Lisa Shapiro, vice president of health policy at First Focus, a bipartisan advocacy group for families.

Bruce Lesley, president of First Focus, said advocates expected people to find out they were eligible for Medicaid when they tried to enroll in the exchanges - and they expected to enroll about 4 million kids who are already eligible for Medicaid, but their parents don't know it.

"If you don't have Medicaid expansion, you don't really have a welcome mat out," he said. "So there's a new opportunity, but not if you're really poor."

Many of the states not expanding, such as Mississippi, Louisiana and Alabama, have some of the highest chronic disease rates in the country, said Georges Benjamin, executive director at the American Public Health Association, an advocacy group for improving public health. Benjamin said between 18,000 to 44,000 people die prematurely every year because they don't have insurance. As a former emergency room doctor, he watched people come in because they had blood in their stools, which can be a sign of early cancer, but he knew they would not be able to afford follow-up care. Or people would come in with new-onset diabetes, but they have no regular source of care, and finding a doctor when a patient doesn't have insurance can be impossible.

"They could have a little ache, but they're not insured, so they can't afford care, so they delay going in and it ends badly," he said. "All of those scenarios I've seen repeatedly."

But that doesn't mean individuals shouldn't look for other alternatives - or for coverage for family members who may be eligible.

"Go to the exchange," Benjamin said. "Find out what you're eligible for. You may be eligible for existing Medicaid and not know it."

Those who don't go to the exchanges may find clinics that receive funding from the government to care for the uninsured, and may offer either free services or a sliding-fee schedule, he said. State and local health departments may also have niche care available, such as for tuberculosis, mental health or substance abuse.